Assessment Form:

Assessment Form:
Client Information
Client Name *

First NameLast Name
Date of Birth*
Age*
Pronouns (optional)
If the client is a minor:
Name of Parent/Guardian Completing this Form
Relationship to Client
Contact Information
E-mail *
example@example.com
Phone Number*
Preferred Method of Contact*

PhoneEmail
Reason for Assessment Consultation
Please describe the primary concerns or questions you would like a psychological assessment to help address: *
When did these concerns first begin?*
In what settings are these concerns most noticeable? (e.g., school, work, home, social situations) *
Areas of Concern (check all that apply)*

Learning or academic difficultiesAttention, focus, or executive functioningEmotional concerns (e.g., anxiety, mood, stress)Behavioral concernsSocial or peer relationships difficultiesDevelopmental concernsDiagnostic clarification (e.g., ADHD, learning disorder, autism)School or workplace accomodationsOther
If Other, clarify what it is
Educational/ Occupational Context
Current school or workplace:*
Grade/ Position (if applicable)
Any current or past supports, accommodations, or interventions*

YesNoUnsure
Relevant History (Brief)
Previous psychological or psychoeducational assessment*

YesNoUnsure
Previous counselling or mental health services*

YesNoUnsure
Known diagnosis (if any)
Timing and Urgency
Are there upcoming deadlines or time-sensitive needs? (e.g., school meetings, accommodation requests, funding, workplace requirements)*

YesNo
If yes, please explain
Assessment Goals
What are you hoping to gain from an assessment consultation? (e.g., diagnostic clarity, recommendations, treatment planning, accommodations) *
Consent to Proceed with Consultation

By submitting this form, I understand:

• This information will be used to determine appropriateness and scope of a psychological assessment.
• Submission of this form initiates the assessment consultation process but does not guarantee assessment services.
• Fees, timelines, and next steps will be reviewed during the initial consultation.
Thank you for completing this form. You will be contacted regarding next steps and scheduling.
Should be Empty:

Assessment Form:

Client Information

If the client is a minor:

Contact Information

Reason for Assessment Consultation

Educational/ Occupational Context

Relevant History (Brief)

Timing and Urgency

Assessment Goals